Ophthalmic emergencies for finals
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Ophthalmic emergencies for finals



Eye/ ophthalmology lectures for final MBBS by Dr.Saman Senanayake

Eye/ ophthalmology lectures for final MBBS by Dr.Saman Senanayake



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Ophthalmic emergencies for finals Ophthalmic emergencies for finals Document Transcript

  • Ophthalmic Emergencies Trauma Medical Emergencies  History  1908-1913 Work-related 30 % IOFB ie metal chips from grinding  WW1-WW2 Explosives, shrapnel etc  1950-1976 Road traffic accidents Windscreen injuries, seatbelt law  1987-date War, Sport, recreation Ice hockey, racket Impact How many in Sri lanka? 4500 admissions in the UK 236 lead to loss of vision 50% injuries at home Nature? Blunt 80% Perforating 18% IOFB 1% Trauma  Blunt o o o o o o o o Lid avulsion Periorbital haematoma Blow-out fractures Hyphaema Sphincter rupture Iridodialysis Retinal detachment Choroidal rupture     Ruptured globe Intraocular foreign bodies Chemical burns Non accidental injury Blunt injuries Mechanical waves are transmitted through the globe 1
  • Damage can occur to all intraocular structures Blunt injuries Mechanical waves are transmitted through the globe Damage can occur to all intraocular structures Lid lacerations  Check that the rest of the eye is OK  Management: o Lacerations crossing lid margin, medial canthus, lacrimal apparatus, levator complex or those associated with globe perforations should be referred to the ophthalmologist o All other lacerations may repaired with 6/0 monofilament o Remember tetanus Periorbital haematomas  Causes: o Direct blow to orbital region  Management: o Check for other ocular damage eg orbital floor fracture, globe perforation, hyphaema, fundal examination o If bony injury suspected X-Ray o Cold compresses o Analgesia Blow-out fractures  Causes: o Direct blow to orbital region  Symptoms: o Orbital pain, pain on ocular movements, diplopia, paraesthesia over maxilla  Signs: o Enophthalmos o eye movements o Bony tenderness o surgical emphysema o sensation over V2 distribution  Management: o X-RAY o Refer to ophthalmology/max-fax Hyphaema  Causes: o Direct blow to the eye  Symptoms: 2
  • o Blurred vision, watering, photophobia  Signs: o Blood in the anterior chamber  Management: o Look for globe perforation o Refer to ophthalmologist o Usually admitted o Bed rest o Topical steroids o Reduce intraocular pressure o Secondary bleeds may need surgical evacuation Ruptured globe  Causes: o High velocity injury, blunt or sharp  Symptoms: o Severe pain, loss of vision  Signs: o Subconjunctival haemorrhage, full thickness scleral and corneal lacerations, prolapse of intraocular contents  Management: o Tetanus prophylaxis o X-RAY o Plastic shield o Urgent ophthalmology referral o 1’ repair: restores integrity of globe o 2’ repair: attempt to restore function Intraocular foreign bodies  Causes: High velocity object  Symptoms: Mild to moderate pain, vision may be unaffected  Signs: May be minimal, entry site may not be obvious 3 View slide
  •  Management: o X-Ray o Refer to ophthalmologist  Systemic antibiotics eg ciprofloxacin  Vitreo-retinal surgery Chemical burns  Causes: o Alkalis: rapid penetration o Acids: aggregate with proteins  Symptoms: o Pain, red, photophobia, blurred vision  Signs: o Epithelial loss, conjunctival injection and chemosis, limbal ischaemia, corneal clouding, uveitis Management:      Copious irrigation with 0.9%Na Cl for at least 30min or until neutral pH Urgent referral to ophthalmologist Admission dependent on extent of burn Topical and oral vitamin C Cycloplegia, topical steroids and antibiotics Substance Common alkalis Oven cleaning fluid Drain cleaning fluid Plaster Fertilizers (some) Common acids Battery fluid Lavatory cleaner Bleach Pool cleaning fluid Chemical pH Sodium hydroxide Sodium hydroxide Calcium hydroxide Ammonium hydroxide 14 14 14 13 Sulphuric acid Sulphuric acid Sodium hypochlorite Sodium hypochlorite 1 1 1 1 Non-accidental injury  The problem o 35% of serious eye injuries occur in children <12 yrs o 4% of children attending eye casualty have been abused  Who? o Most children are under 3 years of age o Parents tend to be young, single, from poor social circumstances with a history of being abused  Mechanism o Shaking  Hallmark o Injuries in different stages of healing eg retinal haemorrhages 4 View slide
  •  The consequence o 15% will have permanent physical problems o Virtually all abused children have permanent emotional problems Medical Emergencies Orbital cellulitis (Infection behind the orbital septum)  Causes: Infection from neighbouring structures usually air sinuses  Symptoms: Frontal headaches, fevers, rigors, diplopia, loss of vision  Signs: Pyrexia, lid swelling, proptosis, chemosis, limitation of ocular movements, optic nerve compression  Complications: Blindness, intracranial abscesses  Management:  This is a potentially life threatening condition o Admit for high dose intravenous antibiotics o Urgent CT scan o FBC, blood cultures o ENT opinion Microbial keratitis  Causes: o Gram +ve and -ve organisms e.g. Pseudomonas, pneumococcus, Staph, E.coli, acanthamoeba o Secondary to corneal injury eg foreign body, contact lenses, loose sutures or corneal anaesthesia / exposure  Symptoms: o Pain, red, discharge, photophobia, reduced vision  Signs: o Corneal epithelial defect, localised white infiltrate in the stroma, hypopyon  Management: o Refer to ophthalmologist for admission o Corneal scrapes and intensive topical antibiotics o Isolation cubicle 5
  • Endophthalmitis  Causes: o Post-operative (Staph sp., Strep sp.)  Symptoms: o Red, pain, reduced vision, usually 3-5 days post-op  Signs: o Conjunctival injection, anterior chamber activity, hypopyon, vitritis, hazy view of the fundus  Management: o Urgent referral to ophthalmologist for admission o Aqueous tap / vitreous biopsy and intravitreal antibiotics o Intensive topical antibiotics o Systemic antibiotics Acute angle closure glaucoma  Causes: o Hypermetropia, hypermature cataract  Symptoms: o Pain, reduced vision, haloes around lights, headache, nausea, vomiting  Signs: o Reduced vision, red eye, corneal oedema, mid-dilated pupil, closed drainage angle  Management o Refer to ophthalmologist o Lower intraocular pressure  Medical: Systemic acetazolamide, mannitol, topical pilocarpine and βBlockers  Laser: Nd-YAG iridotomy  Surgical: Iridectomy Retinal Detachment  Causes o Usually as a result of a retinal tear (rhegmatogenous)  Posterior vitreous detachment  Myopia  Trauma  Symptoms o Flashes, floaters, shadow/curtain across vision, painless  Signs o Field defect, reduced central vision if detachment has reached macula, visible elevated retina  Complications o Can lead to complete blindness if untreated o Once macula detached central vision is lost so the aim is to operate before this occurs 6
  •  Surgical management o External approach (scleral buckle) o Internal approach (vitrectomy) Central retinal artery occlusion  Causes: o Atheroma, embolus (carotid artery or cardiac), arteritis, raised intraocular pressure  Symptoms: o Preceding amaurosis, sudden, painless loss of vision or field defect  Signs: o Markedly reduced vision, relative afferent pupillary defect, whitening of the retina with cherry red spot, segmentation of retinal vessels, embolus  Management: o If within 12 hours, then immediate ocular massage, anterior chamber paracentesis, re-breathing into a paper bag o If more than 12 hours, no immediate treatment o ESR, CRP, (FBC) o Aspirin Anterior ischaemic optic neuropathy  Causes: o Arteritic (giant cell arteritis) o Non-arteritic (arterio/atherosclerosis)  Symptoms: o Sudden, painless loss of vision  Signs: o Reduced visual acuity, altitudinal visual field defect, RAPD, pale swollen disc with fine haemorrhages (segmental), later optic atrophy  Management: o Exclude giant cell arteritis  includes history, examination and investigations (ESR, CRP, FBC) o Screen for hypertension and diabetes Giant cell arteritis  Causes: o Systemic vasculitis, over 60 age group  Symptoms: o Temporal headache, scalp tenderness, pain on chewing, general malaise, anorexia and weight loss, girdle pain stiffness and weakness, diplopia, sudden loss of vision  Signs: o Tender superficial temporal arteries, VI nerve palsy, anterior ischaemic optic neuropathy (70% chance other eye will get AION if untreated)  Management: o Raised ESR and CRP 7
  • o Admit o Commence high dose steroids o Temporal artery biopsy Papilloedema  Raised intracranial pressure o MUST EXCLUDE A SPACE OCCUPYING LESION o Idiopathic intracranial hypertension Accelerated hypertension  Causes: o Uncontrolled, undiagnosed systemic hypertension  Symptoms: o Asymptomatic, occipital headaches, blurred vision, transient obscurations  Signs: o Cotton wool spots, haemorrhages, optic disc swelling, hypertensive encephalopathy  Management: o Urgent admission o In severe cases intravenous sodium nitroprusside o In milder cases oral nifedipine or atenolol o Look for secondary causes of hypertension eg renal artery stenosis, phaeochromocytoma Eye movement disorders  Causes: o Brainstem disorders o Cranial nerve palsies o Hypertension, diabetes o Intracranial aneurysm or cavernous sinus lesion o Myasthenia gravis o Muscle disease  Symptoms: o Diplopia (III= complicated, IV= vertical, VI= horizontal) o Others  droopy eyelid, dilated pupil, neurological etc  Signs: o IIIn: Partial or complete ptosis, limitation of ocular movements in all directions of gaze other than abduction, dilated pupil if compressive lesion, undilated if ischaemic  IIIrd nerve palsy + dilated pupil = intracranial aneurysm o IVn: Head tilt to one side, limitation of depression of the eye when looking down & in o VIn: Limitation of abduction of affected eye o Brainstem and muscle disease: Complicated eye movements 8
  • IIIn palsy  Management: o Full neurological examination, check BP and BM o Refer to neurosurgeon, neurologist or ophthalmologist  Cerebral angiogram, arterial clips  Patch, fresnel prisms, botulinum toxin, surgery 9